Provider Demographics
NPI:1225576242
Name:NICOLE GRAHAM
Entity Type:Organization
Organization Name:NICOLE GRAHAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHETAN
Authorized Official - Middle Name:
Authorized Official - Last Name:AMIN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:704-636-5626
Mailing Address - Street 1:1401 W INNES ST
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28144-2574
Mailing Address - Country:US
Mailing Address - Phone:704-636-5626
Mailing Address - Fax:704-636-5641
Practice Address - Street 1:1401 W INNES ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-2574
Practice Address - Country:US
Practice Address - Phone:704-636-5626
Practice Address - Fax:704-636-5641
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-09
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-07063261QP2300X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility